Friday, August 27, 2010

(Editor's note: I discovered last night that Blogger doesn't allow really long comments, so I have taken the liberty of posting my comments about Lyle's post on the NEJM early palliative care trial and the subsequent comment discussion as a full post.)

Well it's been one of those weeks-after-vacation in which it takes you an entire week of madness just to catch up with what you didn't do the week you were gone. Along those lines, I finally read the full paper today, and had the following reflections:

I think the core, talking-point message from the paper is that early palliative care specialist consultation for 'high risk' cancer patients helps our patients: it improves their symptoms and quality of life. These were consistent and moderate effects across the board for this intervention. When it comes to HRQOL improvement for incurable cancer - moderate improvements are a very very positive and gratifying outcome.

Along these lines, the big 'selling point' of this to our friends in oncology who don't particularly object to us but aren't sure what we add is that we are needed/helpful, we improve their patients' lives which is our mutual goal.

I think the real limitation of this study, as others have mentioned as do the authors, is one of generalizability - one center, one patient population, pre-screened (in essence) by their oncologists, and it's unclear what the pall care team did. That said, reading the appendices, what they outline sounds very much like routine palliative care assessment/interventions, nothing fancy: whole person symptoms, disease understanding, coping, communication preference, goals. I don't know how you pre-specify further what it is we do in real life.

Survival: I disagree with those who suggest that the survival finding was some sort of fluke - there's nothing in the study design to suggest this is an error *within the constraints of this protocol*. The fact that it's a secondary outcome doesn't mean it's not a real phenonomenon: it's a basically unbiasable outcome - you're dead or not - and the effect here is huge - 3 months median. Not subtle at all for this patient population. Yes, there could be a flaw in the study design, or this is a statistical mishap, but I don't see anything in particular which would lead me to that conclusion. If this was a RCT of a hypertension drug in which a drop in mean SBP greater than 10mmHg at 3mo was the primary outcome, and a secondary outcome was all-cause mortality at 3 months, and it so happened that there 30% more drug patients died than placebo, you wouldn't dismiss it. In addition, if median survival in the palliative care group was 3 months shorter than non-PC I hope people wouldn't dismiss it outright, b/c they shouldn't. It'd be 'bad press' I guess, but if you believe that patients should have expert asssistance in maintaining 'quality' of life regardless 'quantity' then you should be comfortable with that quantity being shorter. Cf. the recent study looking at abx for pneumonia in advanced dementia that we blogged about (to be sure this was observational not a trial, I'm just using this to illustrate my point) in which those without antibiotics had no worse/and maybe better symptoms and died sooner: that should be ok with all of us. Anyway, I seriously doubt for cancer there'll ever be an association for palliative care specialist interventions with increased mortality for a lot of reasons (patients, generally, want to live and want treatment; anticancer treatments for those near the end are generally ineffective and not life prolonging anyway so even if palliative group patients didn't get them they'd still live as long, etc.). Anyway, for this study, the big question in my mind about survival has to do with the fact that 30% of patients were still alive at the time of censuring - enough to substantially alter the survival outcomes at, say, 5 years. That concern doesn't invalidate the findings within the scope of their protocol.

All of this is to say that I think this study really does raise the question of whether certain palliative interventions in certain patient populations really do help people live longer. Why not, after all? Is there any reason to think expert symptom control, anticipatory guidance/planning, etc. are any more likely to alter survival than, say Tarceva for NSCLCA patients with ECOGs of 3? Nonetheless touting improved survival outside of the specifics of this study are - generalizing it - to be sure, premature.

One of the probably starry-eyed ideas going through my head after reading this is that the real impact of this study should be to, as others have argued in the past (I can't remember who exactly at the moment, maybe Abernathy and Currow et al), do away with the nebulous 'routine care' or 'routine supportive care' as a control intervention for cancer therapy trials. It should be replaced with, instead, specialist palliative care. I know that's practically impossible - there's not enough people to do this etc. - but I think this study, if it does nothing else, should be the beginning of the end of that practice. Routine supportive care, whatever that means, is not a standard.

The media will be the media, but I agree with those who think some in the HPM community mis-fired in playing up the survival benefit (the authors of the paper did not play it up). This is not because the benefit, within the confines of this study, was bogus, but because as others have said the focus on survival shifts focus from our core values and creates unrealistic expectations.

I don't think all the heat generated however is really warranted, and part of me felt like 'Gee, so it's come to this, a skirmish about whether we should be touting or cringing from findings showing we prolong life.' Part of the lack of sobriety in reacting to the survival results, I wonder, is from a tacit recognition of how young we are as a field, how misunderstood many of us feel sometimes, and how sick we are of people outside our field assuming things about us that aren't true (we are the death doctors, we casually hasten death, we don't support our patients' will to live despite the odds, etc.) - such that there is a little triumphant 'See! We don't kill people!' aspect to this....

That aside - the cult of mortality (as a meaningful outcome divorced from other considerations, particularly in patients with chronic, life-limiting, morbid conditions) is pernicious to medicine, research, society, and our patients. And, I think as a community we don't want to lose site of the larger war, just to celebrate this single battle. *Forgive the martial metaphor - I can't come up with anything more appropriate at the moment.

What we do improves the lives of our patients and their families, it helps them get the medical care that they actually want and helps them meet their goals. If it improves mortality, great; if not, no problem because adding a few months of life is not what all our patients want given the consequences.

One doesn't want to be too naive, however. "You had me at 'palliative care improves HRQOL'..." is what you hope oncologists, other referrers, and payers will say, but I know data about mortality and cost savings are taken seriously by many of our key constituents, so it should be discussed, and goddammit we should be proud of what we do, and this study gives us good reason to be, and I cannot imagine how long term this trial will be nothing other than a boon to our field and to our patients (by improving access to our services).

I hope David Weissman will forgive me for paraphrasing his response to the discussion about this trial: "If I'm a life-prolonging intervention, does that mean I'll have to discontinue myself when a patient is ready to die?" Funniest thing I've heard all week.

Friday, August 27, 2010
by Drew Rosielle MD ·

Monday, August 23, 2010

Having informed, compassionate discussions regarding goals of care and resuscitation status takes a lot of effort on all parties involved. But despite all the articles and advice about 'breaking bad news' I have not seen anyone formally discuss the very sensitive act of placing a DNR bracelet on the patient.

Other people have such bracelets declaring the person is allergic to penicillin or diabetic; mine says, "NJ, WI DNR Order on File. DO NOT RESUSCITATE." It also has my name, my DNR ID number, and a toll-free number someone can call if they are confused about the instructions.

Quick little call for help from the Pallimed readership to get palliative medicine more attention on a national scale at the 2011 South by Southwest. Two submissions I am involved in got short-listed in the first ever Health Track at the Interactive portion of the festival. And right now is the public voting session called 'PanelPicker' which accounts for over 30% of the final score.

Many of the examples I will draw from for the two sessions will come right from the pages of palliative care. The mostly non-medical audience numbered 13,000+ in Spring 2010 and is growing. SXSW Interactive is a place for emerging technologies and ideas to get a lot of attention and I would love to put HPM in that spotlight. And if these panels get picked I will be featuring all of you the Pallimed readers who have made this fun 'night job' such a treat.

You have this week to go register, log in and vote for these two proposals and if you could be so kind leave a supporting, encouraging comment that would be fabulous.

Information needed to register: name, email address and if you are planning to go to SXSW. You will NOT be signed up for an email list.

(NOTE: Keep checking this post for frequent updates to news orgs, blogs, etc talking about this story, then go comment on them!)
As many of you have heard and will be hearing more about, a great new study establishing early palliative care intervention in metastatic non-small cell lung cancer was published this week in the New England Journal of Medicine. This is a state of the science article for many reasons as Lyle eloquently discussed in the lead post for Pallimed this week. The basics of the study show palliative care teams along with standard chemotherapy can improve survival nearly 3 months along with decreased depression and improved quality of life (QOL) scores.

Sunday, August 15, 2010

Have you ever discharged a patient from the hospital and had a gnawing feeling that maybe you could have done more to educate the patient about their disease, medications, and plan of care? Probably so. A recent survey published in the Archives of Internal Medicine tells us that this feeling is based in reality (I'm guessing that you already knew this) and that you are not alone.

Going through training at the University of Minnesota, I think I had more exposure to left ventricular assist devices (LVADs) than the average internal medicine resident in the U.S. Our university had (and continues to have) a very active program, and I remember the conference they had the interns attend to learn what to do and what not to do with LVADs.

What NOT to do:
Don't remove both battery packs at the same time.
Don't let the driveline get infected.
Don't do chest compressions, or you'll dislodge the tubes.

What to do:
If their heart stops, use the hand pump instead of chest compressions.
Call the VAD team if you have any problems.

At this point, I think my eyes were as big as saucers, knowing that as one of the "black cloud" interns that I could soon be dealing with problematic drivelines and trying to figure out how to hand pump someone's heart.

Tuesday, August 10, 2010

Annals of Internal Medicine has a study looking at the long term prognosis/natural history of patients who are mechanically ventilated for a prolonged period. This is a similar topic to one we've blogged about several times before: the chronically critically ill (e.g. here, here).

This is a prospective, single center (Duke) study involving critically ill adults. Patients from all ICUs were included (both medical, surgical, and neuro), and prolonged mechanical ventilation (PMV) was defined as either 21 or more days of mechanical ventilation or at least 4 days of ventilation plus tracheostomy placement with the expectation of prolonged ventilation. Patients with preexisting tracheostomies were exlcuded. Patients were enrolled prospectively (the study involved interviews with patients/surrogates and physicians), and were followed for up to 12 months. Quality of life was measured with a complicated formula involving the EuroQol-5D (an index I am not familiar with).

This study enrolled 126 patients. On the whole, these patients were doing well at baseline: most had no dependencies in ADLs prior to PMV. Median ICU stay was 26 days; hospital 39 days; with 29% going to an LTAC, 18% dying during the index hospitalization, and 30% going to other facilities (e.g. SNF).

A few items about palliative care in the ED, prognosis of delirium, and whether antibiotics improve symptoms in pneumonia. See below the fold. I'm traveling next week, so probably won't blog again myself until later on in August. Summer, ugh, is rapidly fading....

If you have NEVER checked out PCGR, this is a great time to do it. Don't be afraid to comment on any of the posts. Comments show appreciation, insight,and spread good information. And don't forget to share on your Facebook page, Twitter feed, and with your team.

Pallimed: A Hospice & Palliative Medicine Blog Founded June 8, 2005.
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In addition, all opinions expressed on this blog are probably wrong, and should never be taken as medical advice in any form.